Weight-related concerns and behaviors in children and adolescents with type 1 diabetes

Children and adolescents with type 1 diabetes are at risk for disordered eating and unhealthy weight-control practices. This study describes (a) participants' weight perception and weight satisfaction, (b) participants' scores on the Diabetes Eating Problem Survey (DEPS), (c) prevalence of weight-control behaviors, and (d) association of DEPS and weight-control behaviors with race, gender, age, body mass index (BMI), hemoglobin A1c (HbA1c), weight satisfaction, and weight perception. TheAHEAD survey was completed by 295 participants to determine weight satisfaction, weight perception, and weight-control behaviors. Height, weight, and HbA1c were obtained from clinic charts. Older females with higher BMI and elevated HbA1c used significantly more weight-control behaviors. Weight dissatisfaction and heavy weight perception were associated with significantly more unhealthy weight-control practices. Prevention programs should be directed toward the preteen female. Older female teens presenting with higher BMI, elevated HbA1c, weight dissatisfaction, and heavy weight perception should be formally assessed for unhealthy weight-control behaviors. J Am Psychiatr Nurses Assoc, 2008; 13(6), 376-385. DOI: 10.1177/1078390307310154.     

Implications of nocturnal hypertension in children and adolescents with type 1 diabetes

OBJECTIVE

Diabetes is associated with atherogenic risk factors. Hypertension has a major influence on cardiovascular disease in diabetic patients. Ambulatory blood pressure monitoring (ABPM) is useful for identifying nocturnal hypertension. Carotid intima-media thickness (cIMT) is a good measure for identifying subclinical atherosclerosis. This study aimed to evaluate whether nocturnal hypertension affects atherosclerosis in children and adolescents with type 1 diabetes and to investigate the relationship between atherogenic risk factors and cIMT.

RESEARCH DESIGN AND METHODS

ABPM and cIMT were measured in 82 diabetic children and adolescents. We reviewed the hemoglobin A_1c levels, 24-h urine microalbumin excretion, lipid profiles, and duration of diabetes. Nocturnal hypertension was defined as hypertension observed only at night.

RESULTS

Forty-three (52%) subjects were hypertensive, and 30 subjects were classified as having nocturnal hypertension. cIMT was higher in the nocturnal hypertensive group than in the normotensive group (0.44 ± 0.03 vs. 0.42 ± 0.04 mm, P = 0.026). Among children and adolescents with nonhypertensive blood pressure levels in clinic blood pressure monitoring, cIMT and daytime blood pressure were higher in the nocturnal hypertensive group. All ABPM parameters were significantly related to cIMT in multiple linear regression analysis.

CONCLUSIONS

This study showed significantly increased cIMT and daytime blood pressure in diabetic children and adolescents with nocturnal hypertension. ABPM may be a useful method for detecting the macrovascular complications of type 1 diabetes. Longitudinal studies are needed to find the causes of nocturnal hypertension and to evaluate the effect of nocturnal hypertension on atherosclerosis in type 1 diabetes.Type 1 diabetes is a risk factor for the development of cardiovascular disease. Patients with diabetes show a 2- to 10-times greater risk of developing atherosclerotic lesions compared with the normal population (1). Although the complications caused by atherosclerosis usually appear in adulthood, atherosclerotic changes at the endothelial level begin in childhood and progress rapidly in the presence of risk factors (2,3). Therefore, early detection and treatment of risk factors for cardiovascular disease related to type 1 diabetes beginning in childhood are important (4).The prevalence of hypertension is 8% in adolescents between the ages of 12 and 19 years in the U.S. (5), but the prevalence is 73% in children and adolescents with type 2 diabetes and 22% in children and adolescents with type 1 diabetes. These differences suggest that the prevalence of hypertension is significantly higher in young people with either type 1 or type 2 diabetes. A considerable number of patients with type 1 diabetes have two or more additional cardiovascular disease risk factors (6). The need to manage the risks for cardiovascular disease associated with type 1 diabetes should be considered from childhood.Ambulatory blood pressure monitoring (ABPM), which now is used in the diagnosis of hypertension, can detect and characterize changes in blood pressure during daily activities (7) and is superior to clinical blood pressure monitoring in predicting cardiovascular morbidity and mortality (8). The risk of nephropathy increases in adolescents with type 1 diabetes with elevated nighttime blood pressure, as measured by ABPM (9). For these reasons, ABPM may be recommended for pediatric patients with diabetes (7).Carotid intima-media thickness (cIMT) measured by vascular ultrasound also is used as a subclinical marker of hypertensive vascular damage (10). In adults, increased cIMT is an indirect indicator of atherosclerosis and is an important predictor of cardiovascular morbidity and mortality (11). In children, cIMT increases in diseases with increased cardiovascular risk, including diabetes (12) and familial hypercholesterolemia (13). However, there are few studies on the effect of night-time blood pressure, measured by ABPM, on atherosclerosis and macrovascular complications in children with type 1 diabetes.This study was conducted to determine the relationship between nocturnal hypertension and cIMT, a surrogate marker of atherosclerosis, and to search for potential atherogenic risk factors in children and adolescents with type 1 diabetes.     

Leptin levels and body composition in children and adolescents with type 1 diabetes

The purpose of this study was to determine the relationship between serum leptin levels and body composition and to evaluate the variables related to disease in children and adolescents with type 1 diabetes. We studied 49 diabetic patients aged 6-16 years (age: 11.2+/-2.9 years, M/F: 26/23), and 37 healthy controls. Body composition was determined by dual-energy X-ray absorptiometry. Serum leptin, glycated hemoglobin (HbA1c), free thyroxin, thyrotropin, testosterone and estradiol levels were measured in patients and controls. We did not observe significant difference in serum leptin levels between patients and controls. Girls had significantly higher serum leptin levels than boys in both patient and control groups. Serum leptin levels did not correlate significantly with HbA1c, disease duration or daily insulin dose but, correlated positively with body mass index (BMI) and fat mass (FM) in patients as in controls. Body composition in diabetic girls and boys was similar with respective controls. When analyzed by pubertal stage, BMI, lean body mass (LBM), FM, and total bone mineral density (BMD) were significantly higher in pubertal girls with type 1 diabetes compared to prepubertal ones. In pubertal boys with type 1 diabetes, LBM and FM were significantly higher than prepubertal ones. The results of the present study showed that neither serum leptin levels nor body composition was significantly altered in children and adolescents with type 1 diabetes managed with intensive insulin therapy.     

儿童及青少年1型糖尿病患者行为问题分析

目的:探讨1型糖尿病儿童及青少年中行为问题的检出率。方法:首次应用Achenbach儿童行为量表对205例北京地区1型糖尿病患儿和619例健康对照者的行为问题进行评定。并使用SPSS10.0统计软件对两组的调查结果进行分析。结果:①1型糖尿病组行为问题的检出率为20.0%,显著高于健康对照组为8.2%,差异有显著性意义(χ2=25.195,P=0.000)。②糖尿病组检出率居前5位的因子是社交退缩、抑郁、分离焦虑、分裂样和交往不良等,在交往不良和社交退缩的方面,糖尿病组和健康对照组间存在差异有非常显著性意义(χ2=8.320,12.357,P=0.004,0.000)。结论:①1型糖尿病患儿是行为问题发生的高危人群。②在1型糖尿病儿童、青少年患者中以社交退缩、抑郁、分离焦虑、交往不良和分裂样行为问题为主,尤以社交退缩和交往不良更为突出。     

Serum ACE predicts severe hypoglycemia in children and adolescents with type 1 diabetes

OBJECTIVE: To investigate whether risk of severe hypoglycemia is related to serum (S) ACE level during intensive treatment in type 1 diabetic children. RESEARCH DESIGN AND METHODS: A cohort of 86 intensively treated type 1 diabetic patients was studied during 1999-2000. In 1999, the age range was 7-19 years (median 12.8), diabetes duration was 1.2-14.7 years (5.3), insulin dose was 0.4-1.7 units x kg(-1) x 24 h(-1) (1.0), and the HbA(1c) year mean was 4.7-10.2% (6.8). HbA(1c), insulin doses, and events of severe hypoglycemia (needing assistance from another person) were prospectively registered at regular visits, scheduled quarterly. S-ACE was determined once. RESULTS: Severe hypoglycemia was correlated to S-ACE (r = 0.22, 95% CI 0.01-0.41, P = 0.0093). The square root of severe hypoglycemia was correlated to S-ACE (r = 0.27, 95% CI 0.06-0.45, P = 0.0093). Patients with S-ACE at the median level or above (n = 44) reported a mean of 3.0 yearly events of severe hypoglycemia compared with 0.5 events in patients with S-ACE lower than the median (n = 42) (P = 0.0079). Of the patients with an S-ACE at the median level or above, 27 (61%) reported severe hypoglycemia, compared with 17 (40%) patients with an S-ACE lower than the median (P = 0.0527). Insulin dose, HbA(1c), age, onset age, duration, C-peptide, and sex did not differ between these two groups. S-ACE was negatively correlated with age (r = -0.27, 95% CI -0.46 to 0.07, P = 0.0265) but not with HbA(1c), duration, or blood pressure. CONCLUSIONS: The elevated rate of severe hypoglycemia among patients with higher S-ACE suggests, among other factors, that a genetic determinant for severe hypoglycemia exists. Further evaluation is needed before the clinical usefulness of this test can be elucidated.     

Thyroid autoimmunity in children and adolescents with type 1 diabetes: a multicenter survey

OBJECTIVE: To investigate thyroid autoimmunity in a very large nationwide cohort of children and adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS: Data were analyzed from 17,749 patients with type 1 diabetes aged 0.1-20 years who were treated in 118 pediatric diabetes centers in Germany and Austria. Antibodies to thyroglobulin (anti-TG) and thyroperoxidase (anti-TPO) were measured and documented at least once in 7,097 patients. A total of 49.5% of these patients were boys, the mean age was 12.4 years (range 0.3-20.0 years), and the mean duration of diabetes was 4.5 years (range 0.0-19.5 years). A titer exceeding 100 units/ml or 1:100 was considered significantly elevated. RESULTS: In 1,530 patients, thyroid antibody levels were elevated on at least one occasion, whereas 5,567 were antibody-negative during the observation period. Patients with thyroid antibodies were significantly older (P < 0.001), had a longer duration of diabetes (P < 0.001), and developed diabetes later in life (P < 0.001) than those without antibodies. A total of 63% of patients with positive antibodies were girls, compared with 45% of patients without antibodies (P < 0.001). The prevalence of significant thyroid antibody titers increased with increasing age; the highest prevalence was in the 15- to 20-year age group (anti-TPO: 16.9%, P < 0.001; anti-TG: 12.8%, P < 0.001). Thyroid-stimulating hormone (TSH) levels were higher in patients with thyroid autoimmunity (3.34 microU/ml, range 0.0-615.0 microU/ml) than in control subjects (1.84 microU/ml, range 0.0-149.0 microU/ml) (P < 0.001). Even higher TSH levels were observed in patients with both anti-TPO and anti-TG (4.55 microU/ml, range 0.0-197.0 microU/ml). CONCLUSIONS: Thyroid autoimmunity seems to be particularly common in girls with diabetes during the second decade of life and may be associated with elevated TSH levels, indicating subclinical hypothyroidism.     

Vitamin D deficiency is associated with retinopathy in children and adolescents with type 1 diabetes

OBJECTIVE

To examine the hypothesis that vitamin D deficiency (VDD) is associated with an increased prevalence of microvascular complications in young people with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In a cross-sectional study of 517 patients, 25-hydroxyvitamin D was measured. Retinopathy was assessed by 7-field stereoscopic retinal photography, peripheral neuropathy by thermal and vibration threshold testing, and microalbuminuria by albumin excretion rate or albumin-to-creatinine ratio.

RESULTS

Retinopathy prevalence was higher in cases with VDD versus sufficiency (18 vs. 9%, P = 0.02); deficiency was not associated with microalbuminuria or neuropathy. In logistic regression, retinopathy was associated with VDD (odds ratio 2.12 [95% CI 1.03–4.33]), diabetes duration (1.13, 1.05–1.23), and HbA_1c (1.24, 1.02–1.50).

CONCLUSIONS

VDD is associated with an increased prevalence of retinopathy in young people with type 1 diabetes. The inflammatory and angiogenic effects of VDD may contribute to early retinal vascular damage; however, further investigations are warranted.Vitamin D deficiency (VDD) has been implicated in the development of diabetes complications based on studies in mice, cell cultures, and adults with diabetes (1–6). Vitamin D may confer protection via inhibition of inflammation, downregulation of the renin-angiotensin system, improved insulin secretion, and an antiproliferative effect on endothelial cells (1). In a mouse model of ischemic retinopathy, 1,25-dihydroxyvitamin D₃ [1,25(OH)₂D₃] inhibited retinal neovascularization (5), while in cell culture it inhibited endothelial cell proliferation (6). The severity of diabetic retinopathy was inversely related to serum 1,25(OH)₂D₃ levels in adults with type 2 diabetes (2). However there are no studies examining vitamin D and complications in young people. We examined the hypothesis that vitamin D deficiency is associated with microvascular complications in adolescents with type 1 diabetes.     

Urinary transforming growth factor-beta1 and alpha1-microglobulin in children and adolescents with type 1 diabetes

OBJECTIVE: Transforming growth factor (TGF)-beta1 is an important mediator in the pathogenesis of diabetic nephropathy. Urinary TGF-beta1 reflects TGF-beta1 production in the kidney, and alpha1-microglobulin tubular dysfunction. These 2 markers were studied in the early phases of type 1 diabetes. RESEARCH DESIGN AND METHODS: There were 113 type 1 diabetic children and adolescents (mean +/- SD: age 14.1 +/- 2.9 years, and diabetes duration 7.4 +/- 2.9 years, HbA1c 9.3 +/- 1.5%) and 39 healthy subjects (age 13.8 +/- 2.8 years) who participated in the study. Of the diabetic patients, 105 were normoalbuminuric (2-3 consecutive overnight urinary albumin excretion rates [AERs] <20 microg/min) and 8 had microalbuminuria (at least 2 AERs 20-200 microg/min). Overnight urinary TGF-beta1 and alpha1-microglobulin levels were measured and the results expressed as the ratio to urinary creatinine concentration. RESULTS: Data are medians (range). Diabetic patients had higher urinary TGF-beta1 levels than those of control subjects: 0.9 ng/mg (0.05-122.3) vs. 0.3 ng/mg (0.05-2.2) creatinine, respectively (P = 0.003). Urinary TGF-beta1 levels correlated with urinary glucose (r = 0.2, P = 0.03) and alpha1-microglobulin (r = 0.2, P = 0.02) levels, but not with HbA1c, AER, age, or duration of diabetes. In 43 patients with urinary TGF-beta1 above the control levels, urinary TGF-beta1 levels correlated with urinary glucose (r = 0.6, P < 0.001) and alpha1-microglobulin (r = 0.6, P < 0.001) levels. Diabetic patients had higher urinary alpha1-microglobulin levels than those of control subjects: 4.8 microg/mg (0.6-48.8) vs. 2.7 microg/mg (0.8-11.6) creatinine, respectively (P < 0.001). Alpha1-microglobulin levels correlated with AER (r = 0.2, P = 0.02), HbA1c (r = 0.3, P = 0.001), urinary glucose (r = 0.5, P < 0.001), and urinary TGF-beta1 levels. CONCLUSIONS: An early rise in urinary TGF-beta1 levels was observed in young type 1 diabetic patients. Urinary TGF-beta1 is associated with 2 interrelated tubular markers, alpha1-microglobulin and urinary glucose.     

Diagnostic potential of oxidative stress markers in children and adolescents with type 1 diabetes

OBJECTIVES: To validate the diagnostic utility of oxidative stress markers in the evaluation of young type 1 diabetics, as suggested elsewhere. DESIGN: Advanced oxidation protein products (AOPP), thiobarbituric acid-reactive substances (TBARS) and total antioxidant status (TAS) were measured in sera from diabetics, their siblings and controls, with diagnostic potential evaluated by ROC analysis, and related to diabetes clinical parameters. RESULTS: In diabetics AOPP and TBARS were elevated, TAS decreased. Similar alterations were observed for AOPP and TAS in their siblings. AOPP and TAS were good indicators of diabetes. AOPP and TBARS correlated with HbA1C (independent predictor), but were poor markers of non-adequate glycemic control. The cardiovascular disease risk factors were independent predictors of TBARS concentrations. CONCLUSIONS: AOPP accumulation and TAS reduction seem to precede diabetes and might be considered as susceptibility indicators in relatives, but not as diabetes markers in general population (no diabetes specificity has been shown). Application in monitoring of metabolic control is not validated.     

1型糖尿病儿童及青少年患者生存质量调查分析

目的调查1型糖尿病儿童及青少年患者的生存质量。方法采用儿童生存质量普适性核心量表和应对方式问卷分别对63例1型糖尿病儿童、青少年患者及63名患者家长进行调查。结果 1型糖尿病儿童及青少年患者生存质量总均分为(84.84±11.31)分,糖尿病患者家长的应对方式主要以成熟的应对方式(例如:解决问题、求助)为主,糖尿病儿童及青少年患者的年龄、是否独生子女、测血糖者、胰岛素注射工具和家长自责影响患者生存质量。结论关注非独生子女、青少年糖尿病患者的生存质量,鼓励儿童及青少年患者自己测血糖,以提高其自我管理能力。     

Lipid peroxidation and erythrocyte membrane permeability in children and adolescents with diabetes mellitus type 1

The content of malonic dialdehyde (MDA) in erythrocytes and blood plasma as well as the specificity of erythrocyte membrane permeability (EMP) was studied in case of children and teenagers with insulin-dependent diabetes mellitus (IDDM) with respect to a duration and compensation degree of the disease. Eighty-seven children and teenagers with IDDM, aged 7 to 16, and 23 age-matching healthy children and teenagers were examined. The MDA content in erythrocytes and plasma of sick children was found to be increasing yet at the disease onset and did not depend on a duration and compensation degree of diabetes. Erythrocytes of sick children had a lower resistance to the hemolytic action of urea and a higher permeability. As the disease duration was increasing, there was a higher EMP observed at earlier diabetes stages and its decrease with the progressing of diabetes.     

Safety and effectiveness of insulin pump therapy in children and adolescents with type 1 diabetes

OBJECTIVE: To evaluate the safety and effectiveness of insulin pump therapy in children and adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS: All 95 patients who began insulin pump therapy at Johns Hopkins Hospital between January 1990 and December 2000 were included in the study. The mean age was 12.0 years (range 4-18), and 29% of the patients were <10 years old. Data were obtained by chart review beginning 6-12 months before pump start. The median duration of follow-up was 28 months. RESULTS: There was a small but significant decrease in HbA(1c) at 3-6 months after pump start (7.7 vs. 7.5%; P = 0.03). HbA(1c) levels then gradually increased and remained elevated after 1 year of follow-up; however, this association was confounded by age and diabetes duration, both of which were associated with higher HbA(1c) levels. After adjusting for duration and age, mean HbA(1c) after pump start was significantly lower than before pump start (7.7 vs. 8.1%; P < 0.001). The number of medical complications (diabetic ketoacidosis, emergency department visits) was similar before and after pump start. There were fewer hypoglycemic events after pump start (12 vs. 17, rate ratio 0.46, 95% CI 0.21-1.01). CONCLUSIONS: This study suggests that pump therapy is safe and effective in selected children and adolescents with type 1 diabetes.     

Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes

OBJECTIVE: To compare the prevalence of diabetes complications and their risk factors in youth with type 1 versus type 2 diabetes. RESEARCH DESIGN AND METHODS: We performed a comparative clinic-based study of 1,433 patients with type 1 diabetes and 68 patients with type 2 diabetes aged <18 years from New South Wales, Australia. Retinopathy was assessed by seven-field stereoscopic retinal photography; albumin excretion rate from three consecutive, timed, overnight urine collections; peripheral neuropathy by thermal and vibration threshold; and autonomic neuropathy by pupillometry. HbA(1c) (A1C) and lipids were measured in all patients and C-peptide in patients with type 2 diabetes. RESULTS: In patients with type 1 versus type 2 diabetes, median (interquartile range) age was 15.7 years (13.9-17.0) and 15.3 years (13.6-16.4), respectively (P = 0.2), whereas median diabetes duration was 6.8 years (4.7-9.6) and 1.3 years (0.6-3.1), respectively (P < 0.0001). Retinopathy was significantly more common in patients with type 1 diabetes (20 vs. 4%, P = 0.04), while microalbuminuria and hypertension were significantly less common (6 and 16% in type 1 diabetes vs. 28 and 36% in type 2 diabetes). Rates of peripheral and autonomic neuropathy were similar (27 and 61% in type 1 diabetes vs. 21 and 57% in type 2 diabetes). In multivariate analyses, microalbuminuria was significantly associated with older age (odds ratio 1.3 [95% CI 1.2-1.5], P < 0.001) and systolic hypertension (3.63 [2.0-6.3], P < 0.001) in type 1 diabetes, while only higher A1C (1.7 [1.3-2.9], P = 0.002) was significant in patients with type 2 diabetes. CONCLUSIONS: Youth with type 2 diabetes have significantly higher rates of microalbuminuria and hypertension than their peers with type 1 diabetes, despite shorter diabetes duration and lower A1C. The results of this study support recommendations for early complications screening and aggressive targeting of glycemic control in patients with type 2 diabetes.     

The care of children and adolescents with type 2 diabetes

The prevalence of Type 2 diabetes has dramatically increased in children and adolescents over the past 10 years. Type 2 diabetes is characterized by insulin resistance and high insulin levels. Reasons cited for the rise of this condition in children and adolescents are speculated to stem from obesity because of a rise in sedentary behavior, nonnutritious food choices, and genetic predisposition. A high recurrence rate in families shows that therapy for children and adolescents must involve the entire family to be successful. Treatment recommendations vary depending on severity but include nutrition, exercise, and medication. Assessment of the patient's and family's willingness to change their current lifestyle behaviors is an integral part of treatment. Nutrition and exercise goals should be made on an individual basis to meet the needs of the patient. Success of therapy is difficult to measure because this is a chronic condition being diagnosed in young people. As in any chronic condition, success of therapy is difficult to measure.